Provider Demographics
NPI:1841263209
Name:CORRAL, KENT RICHARDSON (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:RICHARDSON
Last Name:CORRAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:803 W LOWRY LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-4711
Mailing Address - Country:US
Mailing Address - Phone:813-348-0224
Mailing Address - Fax:813-872-6792
Practice Address - Street 1:4700 N HABANA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7160
Practice Address - Country:US
Practice Address - Phone:813-348-0224
Practice Address - Fax:813-872-6792
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0035361173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL219133OtherAVMED
FL30392OtherBCBS
FL30392AMedicare ID - Type UnspecifiedGROUP K6668
FL30392OtherBCBS